What is the most important trait in a doctor?

Medical errors are estimated to be the third leading cause of death in America’s hospitals. Though some of these errors are beyond physician control, many are the direct result of physician action and inaction. I spend a lot of time thinking about how to reduce these errors and I (like many of my peers) lose sleep over the mistakes I witness.

When you ask patients what quality is most important in a physician, they often answer, “empathy.” I think that’s close, but not quite right. I know many “nice” and “supportive” doctors who have poor clinical judgment. When it comes to excellent care quality, one personality trait stands out to me — something that we don’t spend much time thinking about:

Curiosity.

A physician with a curious mind doesn’t necessarily know all the answers. He may not be the “smartest” graduate of his medical school. But he is a great detective, and doesn’t rest until problems are solved. This particular quality isn’t nurtured in a system that rewards partial work ups, rapid patient turnover, and rushed documentation. But some doctors retain their intellectual curiosity about their patients — and to the extent that they do, I believe they can significantly reduce medical errors.

Many of the preventable adverse events I have witnessed (outside of procedure-based errors) began with warning signs that were ignored. Examples include abnormal lab tests that were not followed up in a timely manner, medication side effects that went unrecognized, copy errors in drug lists, and subtle changes in the physical exam that were presumed insignificant. All of these signs trigger the curious mind to seek out answers in time to head off problems before they evolve into real dangers.

Of course, there are other qualities that make a physician excellent: wisdom, experience, kindness, and a grounding in evidence-based practice come to mind. But without an engaged mind fueled by genuine curiosity, it’s hard to retain the vigilance required for continued good outcomes.

Curiosity may have killed a cat or two, but I’ve seen it save a large number of patients.

What is the most important trait in a doctor? 21 comments

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John C. Key MD

There’s an old saw that the keys to being a successful practicing physician are availability, affability, and ability…in that order. Curiosity should be important too but sadly the decline in general internal medicine–those guys that we used to call “diagnosticians” seems to have made cognitive curiosity rare–or at least uncommon. When I was an intern my Chief paid a compliment to a diagnostician–“if you sent Herb a patient with everything normal except a Sed Rate of 4, he will find out why.” Today it’s hard to even find a diagnostician much less one who wants to sort out a challenging diagnosis.

SteveCaley

I fell in love with diagnosis – I have never let go of the passion. As a third-year medical student, I checked out a fellow in the Boston VA, and confidently told my attending that this old veteran had Guillain-Barre syndrome. I got a nice pat on the head, and encouraged my cleverness, and that if I kept thinking like that, I’d make for quite an internist some day.
The next day, the guy’s face fell, and he couldn’t move his arms. BAANG! as John Madden used to say. BOOM! I hit that diagnosis just right, just like Howie Long coming up out of nowhere for the sack. There’s no feeling like that in the world.
I’ve got others.
But nobody cares any more. Our writer said –

Patient Kit

When I was a complicated zebra with a nonunion pathological femur fracture that wouldn’t heal, I thought I was an interesting case, a mystery for my docs to solve. When I was a lucky patient with early stage “easy” OVCA, I thought of myself as kind of a boring case. So, it comes as a shock to me to hear that many doctors prefer the easy cases and do not want the intellectual challenge of the difficult cases and the thrill that must come with resolving them. This apparent change is not comforting to me as a patient.

SteveCaley

In referencing the meta-study, I noted the following from the Journal of Patient Safety: September 2013 – Volume 9 – Issue 3 – p 122–128 by a member of the Safe Patient Project:There has been no lack of contention about the prevalence of PAEs (Patient Adverse Events), which herein will be considered synonymous with medical errors that cause harm to patients… Here, adverse events are equated with medical error. This is a deliberately wrongful use of the terms.

An adverse event is an unwanted outcome. An error is a failure of a person to do what is reasonably best in a certain circumstance.

Most motor vehicle accidents are the results of a driver error; but not all of them.this does not include near misses that do not harm patients. The first estimate of medical errors that received widespread attention was declared by the IOM in its now- famous book called “To
Err is Human.”The IOM provided 2 estimates of the number of deaths from medical errors, but careful inspection of the origin of these estimates show that they were based on data that are now quite old. The earliest estimate originated from the Harvard Medical Practice Study in which 30,000 randomly selected discharge records from 1984 in 51 New York hospitals were examined. The investigators found that serious adverse events occurred in 3.7% of the hospitalizations. Of the adverse events, 58% were attributable to error (i.e., they were preventable). Of this fraction, 13.6% resulted in death. Extrapolated to 33.6 million hospitalizations nationwide in 1997, simple arithmetic yielded the following: 33,600,000 × 0.037 × 0.136 × 0.58 = 98,000 deaths per year. Another study of 15,000 medical records from Colorado and Utah in 1992 found lower rates of adverse events and death, from which the IOM estimated 44,000 deaths nationwide per year. Although physician reviews reveal adverse events due to “negligence,” which was about 28% to 29% in both studies, a later publication from the IOM suggested that the 44,000 to 98,000 deaths did not include errors of omission. Because the New York study included a larger sample, the deaths-per-year figure of 98,000 attributed to the IOM is the estimate most often quoted. In fact, the IOM declared that the “number of deaths [per year] due to medical error may be as high as 98,000.”
I find it astonishing that people only wish to abstract a number from the TEIH study in 1999, and none of the findings. The entirety of the report was about how to reduce medical errors in hospitals. This has not only been ignored for fifteen years – the underlying problems have accelerated as a result of “cost-savings” measures in healthcare.
The willingness to mash together patient adverse events, medical error and medical negligence helps nobody. It produces the false solution that make our movies so entertaining – find the bad guy and shoot him. But not every bad outcome is due to a bad guy – TEIH itself says that most errors are done by competent and conscientious providers. The system is broken. But shooting people is fun, so we do that instead.
This willingness to accept simplistic black-and-white thinking is not unlike the mindset during the Weimar – give people relief from having a conscious, and many will choose to follow.

Suzi Q 38

I learned how valuable a good clinician was when specialists were trying to figure out if I had a cervical spine injury, or MS. The doctors I had were just giving me the run-around, and had been for a year and a half.
I was getting worse.

Thank goodness my son knew quite a few medical students who knew of a neurologist practicing in a city about an hour from where we lived. I checked her credentials, and they were not from a first tier, or even a 2nd tier medical school.

All I was told was that she went to medical school with one of the students (friend of my son’s) and she was “the best clinician he had ever known.” She was working for a rather small, not well known HMO.

I didn’t care. I went to her, and she was fantastic. Methodic attention to detail, asked all the right questions, and gave me the best exam that I had had to date. Told me what to do and what to expect from my condition. She reviewed all the info, and told me that she felt I had an injury, rather than MS. She told me to go ahead with the surgery, as she did not feel, given my battery of test results, that I had MS.

I tried to get another appointment with her 4 months later, but she had moved. I found her on the internet, and drove a little further to get to see her.

I did not care. I have had several “bad” doctors. When I get a good one, I will follow h/her and drive further if necessary to keep them as my doctors.

querywoman

Too bad more doctors are not more curious about skin disease. Blaming it all on “picking at it” doesn’t explain why it happened in the first place.

SteveCaley

Touche. In the last year, I’ve seen erythema multiforme as a drug eruption from contaminated heroin, and painless zoster. The problem with diagnosis of painless zoster is that it is not permitted to exist in theory. It only occurs in practice, and rarely so.
Neither one is treatable, or needs treatment. The zoster is itchy but endurable.

querywoman

I’ve been in the hospital 4 times with my current internist. The first 2 times were for cellulitis of the legs. She had send me to a vascular surgeon for followup. I loved him, but didn’t think he was doing me any good. Eventually, he told me to get a dermatologist, and I agreed.
My derm is well-known, respected, nongreedy. My internist told me once he shouldn’t be giving me cortisone shots. I was thinking, yeah, I’m supposed to have nothing. It was two years before he even let me have one, and he doesn’t always use them.
She doesn’t seem to show much interest in his treatments, when I think she should. However, she got interested when I told her he’s not a botox doctor. Cosmetic doesn’t get his priority. And he’s the closest major medical center to her.

Sometimes I think of replacing her, but she’s really good. My minister liked her during my first hospitalization for pneumonia. That’s a good standard. She was thrilled to meet him, since she knew most of my immediate family was gone.
However, my endocrinologist in the same building as her is very interested in my skin, and he really looks at it. He monitors my Vitamin D levels, and believes it is autoimmune.

querywoman

Is Steve Caley your real name? I don’t see you on google. Do you have ad different first name? Something like John Steven or John Stephen?

SteveCaley

Thanks, it’s a pen-name, partially.

querywoman

The new anonymity of the internet liberates us to say what we want.

querywoman

I take low dose doxepin for itch. You are really smart. You didn’t blame those skin diseases on “picking at it.” Sure, my derm does it some, but I’ve got him trained. I argue with the young residents at times.
I told him recently I understand it better now. As my eczema lesions slowly peel off, sometimes old strange painful lesions resurface. I understand now that they didn’t go away, but somehow more tissue formed around it to cushion it.

Karen Ronk

Absolutely 100% correct. This may be the best (and most succinct) post I have read on KMD. So now the question is, how do we find those doctors with that most crucial of traits?

iphone12

Agree about this being the best post I have read on KMD. In fact, it
was quite timely as recently, the lack of curiosity among doctors has
been my number one complaint.

I would like to know also about how to find physicians who are curious. What are good questions to ask the doctor’s medical assistant, PA, or nurse that might give an indication of this?

Perhaps writing about how to find these doctors might be a future blog entry for Dr. Jones on KMD.

lurking for answers

I would go so far as to say that curiosity is the most important trait for excellence in any field. Unfortunately, it is often beaten out of children in school, where the test is taught, not thinking. Conformity is the new normal and questioning causes trouble. With most of my doctors, finding causes is not as important as ensuring stability and once stability is achieved, questions are no longer accepted regardless of possible improvement in my level of functioning. There is no “better,” no “cause,” no “cure,” just an expectation of “good enough.”
In every culture, evil was unleashed because of curiosity: Eve, Pandora, and that cat.

Patient Kit

Re those curious cats, they don’t call me Kit for nothing. 😉 And here I am, still standing, in spite of my intense sense of curiosity. Good thing I get nine lives. Question authority, resist conformity, ask lots of questions, think for yourself, don’t be afraid to rock that boat, don’t sell your soul for the illusion of security and stability, go to the beach and watch a mama sea turtle lay her eggs (or stop and smell the roses). Reading through some of these comments, I realize what a child of the sixties I really am. Get in touch with your inner surfer girl and your desire to rage against the machine.
In the words of one of our regular doc commenters here (DeceasedMD): What a world!

lurking for answers

Curiosity is also both a blessing and a bane for patients as well. An informed patient will search, learn and confirm as much information about their illness as they can, so as to participate fully in the care of only body they have. Many doctors do not welcome that participation, the good ones will encourage it. It is not by my doctors hands or efforts that I am not in a wheelchair, on dialysis or dead, but by my own. I asked my nephrologist why I could not find a good primary doctor to quarterback for me and he said:” because you scare them to death!” As well as curiosity, a good doctor has courage: the courage to tell me make changes, the courage to look down unexplored paths and the the courage to stand with me in the face of conditions they neither understand nor control. “Good enough” is not an answer; I will NOT go gently into that good night!

Suzi Q 38

I agree.
The couple of rotten doctors that I have had lacked character and were liars.
I was so shocked and surprised that they would totally lie when in trouble.
Good thing I had already ordered the medical records and had proof of their lying, not that it matters much.

I think that the administration at most hospitals are so used to doctors lying that they are not surprised or quick to reprimand when caught with proof of the truth.

Only two of my 6 doctors were liars. Not bad.
At least not all of them were liars.

It just makes it worse for the others.

I no longer trust doctors.

Wendy Felsenthal

yep

SteveCaley

We just can’t seem to shake this attitude out of every aspect of our culture, no matter how hard we try. The folks in the Middle East have continued the tradition of “shoot the bad guy” for a half-dozen millennia (and that’s just on record) and it hasn’t stopped. When we bring it here and try it, it doesn’t fix anything here either.

querywoman

Yup. I often comment that hysterectomies are easy to get in training hospitals because they need patients for training purposes. And post-op complications are psychological!
Cancer screening and the removal of organs must stop being the gold standard for women’s health care!